|Year : 2018 | Volume
| Issue : 2 | Page : 54-59
Low awareness about breast self-examination and risk factors of breast cancer in Benghazi, Libya
FatmaYousuf M Ziuo1, Ahmed Ahmed Twoier1, Tahani Ragab Huria2, Fayek Salah El-Khewisky2
1 Department of Family and Community Medicine, Faculty of Medicine, University of Benghazi, Benghazi, Libya
2 Department of Pharmacology, Faculty of Medicine, University of Benghazi, Benghazi, Libya
|Date of Web Publication||29-Mar-2018|
Dr. FatmaYousuf M Ziuo
Department of Family and Community Medicine, Faculty of Medicine, Department of Family and Community Medicine, Faculty of Medicine, University of Benghazi, Benghazi
Source of Support: None, Conflict of Interest: None
Background: Breast cancer is the most common cancer in women in the Eastern Mediterranean region and the leading cause of cancer mortality worldwide. Objectives: The study aimed to ascertain the level of awareness about the breast self-examination (BSE) and early detection of breast cancer and risks of breast cancer in the women of Benghazi, the second capital city of Libya. Subjects and Methods: A community-based survey was carried out in Benghazi to assess the knowledge, attitude, and practice of women at Benghazi about BSE and risk and protective factors of breast cancer. Cluster sampling technique was used. 30 clusters were selected during the year 2013. Results: Three thousand women were targeted; 2601 women were interviewed. Their mean age was 36.4 ± 10.9 years; more than half of them were married. The respondents' knowledge about BSE was poor with less than half of them (48.1%) having ever heard about BSE. Less than one-fifth of them (16.9%) knew what is BSE and less than one-quarter (25.7%) had satisfactory knowledge about the recommended frequency of BSE. About 39.0% of the respondents knew how to perform BSE, less than one-quarter of them (22.5%) knew when to start it. However, about three quarters (74.4%) of women considered BSE practice very important based on information from television programs as their source of knowledge (23.8). Less than half (43%) thought that high-fat diet and 42% stated that that physical inactivity are recognized risk factors for developing breast cancer. Conclusions: There is a poor knowledge about BSE and about risk and protective factors of breast cancer even among educated women in Benghazi. Primary prevention and early detection awareness should be the first step for prevention of breast cancer in Benghazi, Libya.
Keywords: Breast, breast self-examination, knowledge, attitude, and practice analysis, primary prevention, survey, women health
|How to cite this article:|
Ziuo FM, Twoier AA, Huria TR, El-Khewisky FS. Low awareness about breast self-examination and risk factors of breast cancer in Benghazi, Libya. Ibnosina J Med Biomed Sci 2018;10:54-9
|How to cite this URL:|
Ziuo FM, Twoier AA, Huria TR, El-Khewisky FS. Low awareness about breast self-examination and risk factors of breast cancer in Benghazi, Libya. Ibnosina J Med Biomed Sci [serial online] 2018 [cited 2019 Dec 6];10:54-9. Available from: http://www.ijmbs.org/text.asp?2018/10/2/54/228900
| Introduction|| |
Breast cancer is the top cancer in women both in the developed and the developing countries. The incidence of breast cancer is increasing in the developing world due to increasing life expectancy, increasing urbanization, and adoption of western lifestyles., Breast cancer ranks as the second cause of cancer death in the Eastern Mediterranean Region. Awareness and early detection of the disease is vital. In 2004, in Libya, breast cancer was the most common malignancy in women as recorded by Benghazi Cancer Registry. It represented 23% of all cancers in women. Therefore, early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control.
Breast self-examination (BSE) is an established preventive health behavior, and it is commonly recommended strategy for breast cancer screening. The American Association of Cancer recommended that BSE for young women should start at the age of 20 and it should be done every month after menstruation., However, older women are recommended to have more intensive assessments such as clinical breast examination (CBE) by a health professional, mammogram, or screening magnetic resonance imaging according to age and clinical risk clinical examination.,
The goal of periodic BSE and CBE is to detect palpable tumors. An additional role of BSE is to increase awareness of normal breast composition so that there is heightened awareness of changes that may be detected during BSE or at some other time. The value of heightened awareness is based on the value of earlier treatment of both nonpalpable and palpable breast cancers., There are no data from Libya on women's awareness of breast cancer in general and BSE in particular. Therefore, this study aims to identify the gaps in the knowledge, attitude, and practices of Libyan females with view to guide health education and care.
| Subjects and Methods|| |
Design and settings
This is a community-based cross-sectional interview survey of women' knowledge, attitude, and practices about BSE in Benghazi carried out during the 5-month period of February–June 2013. A cluster sampling technique was used to choose 30 clusters. 3000 women were randomly selected to represent the women in the city and number proportionate to the size each cluster. The study criteria were nationality; age range and the numbers being proportionatal to the size of each cluster. A total of 3000 women aged 18 years or older were invited; 2601 women were interviewed. The study was approved by the local ethics committee, and informed written consent was obtained before serving the survey.
Precoded interview questionnaires were used to collect data. The questionnaire included four domains. The first included sociodemographic data on age, education, marital status, and occupation. The second domain covered questions relating to knowledge of breast cancer risk and protective factors. The third domain included the seven items that assessed participants' knowledge of BSE (including questions such as: does BSE practice reduce the incidence of breast cancer, ever heard about BSE, age to start, frequency, method, the timing, position, frequency, and details of performance of BSE). The sources of respondents' knowledge about BSE were also ascertained. The attitude and practices of BSE among women in Benghazi were assessed in the fourth domain.
Data are presented as actual numbers, proportions, percentages or means, and standard deviations for summary descriptive statistics. Relations were explored using Chi square test and P < 0.05 was taken to indicate significance.
| Results|| |
Demographics of study population
Of the total 3000 women, 2601 were interviewed (response rate 86.7%). The mean age was 36.4 ± 10.8 years, nearly one-third 846 (32.5%) of participants aged 31–40 years. 44.8% of women who were having University and higher education and <10th of the respondents were illiterate 7.7%. One thousand and six (38.6%) of women were teachers, 796 (30.6%) were homemakers, 301 (11.6%) were students, and 124 (4.8%) were professionals. The study reported that slightly more than half, 1349 (51.9%) of respondents were married, 1028 (39.5%) were single, and less than tenth 224 (8.6%) were divorced or widow [Table 1].
Knowledge about breast self-examination
1080 (41.5%) of participants had good knowledge about BSE; 803 (31%) had fair knowledge; and 718 (27.5%) of them had poor knowledge about BSE. Most of the women knew that practicing of BSE can decrease the incidence of breast cancer (2382 [91.6%]). Less than half of women (1251 [48.1%]) heard about BSE, slightly more than half of females (1387 [53.3%]) knew the correct position for BSE, (1014 [39.0%]) knew how to perform BSE, and [720 (27.7%)] knew the correct age to start BSE practice. Less than one quarter them (586; 22.5%) knew when to start practicing BSE. One-quarter of participants [668 (25.7%)] had correct knowledge about the frequency of BSE, but less than one-fifth (440 [16.9%]) knew BSE.
Perception of the breast cancer risk factors
Regarding risk factors, exposure to medical radiation was stated as a risk factor by nearly two-thirds of the respondents (61%), use of hormonal replacement therapy was mentioned by over half of the women (58.6%), and family history of breast cancer was identified by a similar proportion (58.5%). Artificial feeding was blamed by 57.8%, cigarette smoking by 57.3%, and living and living near high voltage magnetic field by 51.8%. However, less than half (46.8%, 45.7%, and 45.3%) of the respondents implicated use of contraceptive hormone, high fatty meals, and lack of exercise, respectively, as risk factors of breast cancer. Whereas less than one-fifth (17.1%) of respondents associated early menarche with increased risk of developing breast cancer. On the other hand, protective factors from breast cancer recognized by respondents included breastfeeding by more than 4 in five (88.5%), regular vegetable intake, and regular exercise by over two-thirds (68.2% and 65.2%, respectively). Over half of respondents (58.8%) suggested consumption of low-fat food and over one-third (37.1%) mentioned vegetable oils as protective. A minority (10.2%) of respondents considered late marriage as a protective factor.
Knowledge of breast cancer symptoms
The following features of breast cancer were recognized by the corresponding percentages of the respondents: a lump in the axilla (75.6%), differences in the breast size (60.1%), perimenstrual breast pain (53.9%), breast skin changes (49,6%), bloody nipple discharge (43.9%), and any nipple discharge (42.4%). A total of 1172 (43.4%) of respondents could not recall a definite source of knowledge. However, 23.9% reported their source of knowledge as television stations, 19.9% thought it came from multiple sources, 6.3% got these information from family and friends, and only a minority of 3.8% and 2.8% thought that their source of knowledge were lectures and internet, respectively.
Attitudes to breast self-examination and breast cancer
About 74.9% and 22.4% of the respondents viewed them as very important or important, respectively. An extreme minority had a neutral view point (1.2%) or felt it was not important at all (1.5%). Of the respondents who had university or postgraduate education, 47.6% and 47.2% viewed the BSE as very important and important, respectively. There were significant differences between women attitude and their education (χ212= 24.57 and P = 0.01). Highly significant association between women attitude and occupation where among those women who believed the BSE as very important and important, 39.7% were teachers and 29.1% were homemakers (χ152= 32.52 and P = 0.005). There was a significant association between women's attitude toward BSE and their age where (χ26= 16.77 and P = 0.05); women aged 20–50 years, 75.7% believed that BSE practice is very important [Table 2]. There was no significant relationship in women's attitude toward BSE and marital status where χ26= 6.95 and P = 0.32; married women, i.e., 54.1% believe that BSE is not important. Among single women, 45.9% believe that BSE is not important and 38.9% of them believed that BSE is very important.
|Table 2: Women's sociodemographic characteristics and attitude toward breast self-examination practice|
Click here to view
Practice of breast self-examination
Only 12.1% of women regularly perform BSE. There was significant relationship between practice of BSE and the participants' education (χ28= 44.13, P = 0.0001); among those women who regularly perform BSE, 44.1% had university or higher education, 28.6% had college diploma, 16.5% had elementary education, and 4% were illiterate [Table 3].
|Table 3: Participants' sociodemographic characteristics and breast self-examination practices|
Click here to view
There was significant relationship between practice of BSE and women's occupation (χ28= 37.0, P = 0.0001). For instance, of the women who were regularly performing BSE, 40.5% were teachers and 28.9% were homemakers. Furthermore, there was a significant relation between BSE practices and past history and family history of breast cancer where odd ratio = 3.75 (95% confidence interval = 1.86–7.59; P = 0001). Only 1.4% of women in general and only 5% of those who had history of breast cancer were practicing BSE [Table 3]. There was no significant differences between marital status and BSE practices: 56.7% of the married women, 37.0% of single women, and 6.2% of widows and divorced women were practicing BSE regularly (χ24= 5.34; P = 0.25).
| Discussion|| |
The current survey represents an important data about knowledge, attitude, practices of BSE, risk and protective factors of breast cancer among Libyan women at Benghazi. Early detection of breast cancer has a great impact on the mortality and survival rate of patients suffering from breast cancer.
The present survey reported that less than half of women at Benghazi had a good knowledge score about BSE and over half of respondents females had fair or poor knowledge score, a similar result was reported by others in Iraq. Less than half of Benghazi women heard about BSE. This level is better than that reported in Qatar and Bahrain., While a higher level of knowledge were reported in Nigeria (94%), Saudi Arabia (79%), and Kuwait (67.5%).,,,
Knowledge of the Benghazi women of the timing, frequency, and method of BSE was much lower than that recorded in Iraq. Nigerian and Saudi women knew the correct time of BSE performance and Jeddah., About 30.8% of respondents knew the BSE in Iran. However, best responses came from females nurses in UAE, but these may not be a fair comparators because of their health background. Recognized risk factors were identified to variable degrees. Similar but not identical degree of variation was seen in the Iraqi study. About 88.5% of women in the resent study considered breastfeeding as the most important protective factors from breast cancer but regular vegetable intake, regular physical exercise, low-fat food, and vegetable oils play some role. About 17% of Iraqi women were aware that early oophorectomy could have a protective role  but 72.2% were able to identify other preventive measures that included alcohol abstinence, physical activity, healthy diet, maintaining a healthy body weight, and avoiding hormonal therapy.
The low proportions of women practicing BSE regularly in the present study are as poor to those reported from Yemen and Saudi Arabia,, and even better than those reported from Iran, Kuwait, and Egypt.,, The current study and others support the notion that BSE rates are much lower in Eastern Mediterranean region and Arab countries than in many countries in Africa and Asia such as Nigeria with rates of 80% practicing BSE months and Turkey where 52% of Turkish midwives practiced BSE and 43.9% of Turkish female teachers. In Turkey, it was suggested that education and busy social and professional life affects the rates in different directions. It is possible that similar effects worked in our own series and others. Interestingly, BSE was positively associated with a higher educational level in Saudi Arabia and Turkey, employment, family history of breast cancer, and a history of benign breast diseases.,
The present survey revealed that the largest proportion of women could not identify a definite source of knowledge but nearly quarter of them thought it came from TV programs. This is at variance with other studies where most of the information could be traced back to health educator. This provides health care professionals and health organisations an opportunity to address the present deficits via national and local TV stations. The discordance between knowledge and practice needs efforts directed at change management rather than simply informing the public. Positive relation between BSE practices and past history and family history of breast cancer was found in the present study similar to previous reports.,
| Conclusions|| |
The survey indicated that women in Benghazi have positive attitude toward BSE. However, as their knowledge is poor, they will not be capable to to perform effective BSE despite their reported enthusiasm. Moreover, they have poor knowledge about risk and protective factors of breast cancer. This was evident even among educated women. A dual strategy is recommended of combining primary prevention to reduce the risk load in society and early detection to improve the outcome of those detected to have the disease. There is a continuing need for more breast cancer education programs to all women to attract them toward primary prevention and early detection programs. Further research is needed to identify size of the problem nationwide, responses to future corrective plans, and barriers and promoters of screening in general and BSE knowledge and practices in particular.
The authors acknowledges the support from all doctors and staff who worked on this study. The authors are indebted to all the respondents for participation in the study.
All authors contributed to the conception and conduct of the study, data collection and analysis and to drafting, revision, and approval of the manuscript in its final version.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Compliance with ethical principles
The study was conducted in accordance of the principles of the Declaration of Helsinki. The protocol was approved by Research ethics committee of the University of Benghazi.
| References|| |
Anderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A, et al.
Guideline implementation for breast healthcare in low-income and middle-income countries: Overview of the breast health global initiative global summit 2007. Cancer 2008;113:2221-43.
Coleman MP, Quaresma M, Berrino F, Lutz JM, De Angelis R, Capocaccia R, et al.
Cancer survival in five continents: A worldwide population-based study (CONCORD). Lancet Oncol 2008;9:730-56.
Khatib OM, Modjtabai A. Guidelines for the Early Detection and Screening of Breast Cancer. World Health Organization Regional Office for the Eastern Mediterranean Region, 30. Cairo, Egypt: EMRO Technical Publications; 2006.
El Mistiri M, Verdecchia A, Rashid I, El Sahli N, El Mangush M, Federico M, et al.
Cancer incidence in Eastern Libya: The first report from the Benghazi cancer registry, 2003. Int J Cancer 2007;120:392-7.
Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP 3rd
, et al.
American cancer society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin 2003;53:141-69.
Jacob TC, Penn NE, Brown M. Breast self-examination: Knowledge, attitudes, and performance among black women. J Natl Med Assoc 1989;81:769-76.
Baxter N; Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? CMAJ 2001;164:1837-46.
Attia AK, Abdel Rahman AM, Kamel LI. Effect of an educational film on the health belief model and breast self-examination practice. East Mediterr Health J 1997;3:435-43.
Abdel-Fattah M, Zaki A, Bassili A, El-Shazly M. and. Tognoni G. Breast self-examination practice and its impact on breast cancer diagnosis in Alexandria, Egypt. Eastern Mediterranean Health J 2000;6:34-40.
Alwan NA, Al-Attar WM, Eliessa RA, Madfaie ZA, Tawfeeq FN. Knowledge, attitude and practice regarding breast cancer and breast self-examination among a sample of the educated population in Iraq. East Mediterr Health J 2012;18:337-45.
Donnelly TT, Al Khater AH, Al Kuwari MG, Al-Bader SB, Al-Meer N, Abdulmalik M, et al.
Do socioeconomic factors influence breast cancer screening practices among Arab women in Qatar? BMJ Open 2015;5:e005596.
Fikree M, Hamadeh RH. Breast cancer knowledge among Bahraini women attending primary health care centers. Bahrain Med Bull 2011;33:1-8.
Nemenqani DM, Abdelmaqsoud SH, Al-Malki AA, Oraija AA, Al-Otaibi EM. Knowledge, attitude and practice of breast self-examination and breast cancer among female medical students in Taif, Saudi Arabia. Open J Prev Med 2014;4:69-77.
Oluwole OC. Awareness, knowledge and practice of breast self-examination amongst female health workers in a Nigerian community. Sudan JMS 2008;3:99-103.
Radi SM. Breast cancer awareness among Saudi females in Jeddah. Asian Pac J Cancer Prev 2013;14:4307-12.
Alharbi NA, Alshammari MS, Almutairi BM, Makboul G, El-Shazly MK. Knowledge, awareness, and practices concerning breast cancer among Kuwaiti female school teachers. Alex J Med 2012;48:75-82.
Nafissi N, Saghafinia M, Motamedi MH, Akbari ME. A survey of breast cancer knowledge and attitude in Iranian women. J Cancer Res Ther 2012;8:46-9.
Sreedharan J, Muttappallymyalil J, Venkatramana M, Thomas M. Breast self-examination: Knowledge and practice among nurses in United Arab Emirates. Asian Pac J Cancer Prev 2010;11:651-4.
Ahmed BA. Awareness and practice of breast cancer and breast-self examination among university students in Yemen. Asian Pac J Cancer Prev 2010;11:101-5.
Kashgari RH, Ibrahim AM. Breast cancer: Attitude, knowledge and practice of breast self examination of 157 Saudi women. J Family Community Med 1996;3:10-3.
Al-Azmy SF, Alkhabbaz A, Almutawa HA, Ismaiel AE, Makboul G, El-Shazly MK. Practicing breast self-examination among women attending primary health care in Kuwait. Alex J Med 2013;49:281-6.
Salama HA, Elsebai N, Abdelfatah F, Shoma A, Elshamy K. Effects of peer education on the knowledge of breast cancer and practice of breast self-examination among Mansoura university female students. J Am Sci 2013;9:253-61.
Ertem G, Koçer A. Breast self-examination among nurses and midwives in Odemis health district in Turkey. Indian J Cancer 2009;46:208-13.
] [Full text]
Gürdal SÖ, Saraçoǧlu GV, Oran EŞ, Yankol Y, Soybir GR. The effects of educational level on breast cancer awareness: A cross-sectional study in Turkey. Asian Pac J Cancer Prev 2012;13:295-300.
[Table 1], [Table 2], [Table 3]